The choice between vaginal birth after cesarean (VBAC,
"vee-back") and repeat c-section is sometimes presented in black and
white, with some holding the opinion that another cesarean is safest
for your baby. It is true that the c-section scar can give way (uterine rupture)
during labor and that this is on rare occasions life-threatening for
the baby. The decision is not so simple, however, as a c-section also
poses risks to babies. This website can help you consider the full
range of risks involved when making your decision. You can find
detailed information about these risks in Best Evidence: VBAC or Repeat C-Section and Best Evidence: C-Section.

Both
vaginal birth after cesarean and repeat c-section involve some
increased risks to mothers. However, without a clear, compelling and
well-supported need for c-section in the present pregnancy, planned vaginal birth is safer overall
for you than a planned repeat c-section. With supportive care, 75 or
more out of 100 women who plan VBAC give birth vaginally. The others go
on to have another cesarean, primarily for reasons that are unrelated
to the scar.

A planned cesarean offers some advantages over
a cesarean that takes place after labor has started: a planned cesarean
is less likely to involve injury to other organs during surgery, to
lead to infection, and to take an emotional toll.
Nonetheless, whether planned or unplanned, cesarean sections are major
surgery and involve pain, a post-operative recovery period, and greater
risk for mothers in many areas. You can find detailed information about
these risks in Best Evidence: VBAC or Repeat C-Section and Best Evidence: C-Section.

A
VBAC in your current pregnancy is the far safer choice for any future
pregnancies you may have. Each additional cesarean operation increases the amount of internal scar tissue. Increasing scar tissue makes it more and more difficult for the placenta that nourishes the baby to grow and attach normally. This can pose life-threatening risks to babies and mothers. Increasing scar tissue also increases the chance of adhesions, where nearby tissue or organs grow together. Adhesions make cesarean surgery more difficult and risky in future pregnancies. You can find detailed information about these risks in Best Evidence: VBAC or Repeat C-Section and Best Evidence: C-Section.

A VBAC this time around has
other advantages in future pregnancies. If a woman who has a VBAC has
more children, she almost always gives birth vaginally and her uterine scar almost never gives way during future labors.

Even though many caregivers and hospitals do not offer VBAC, dozens of studies involving tens of thousands of women have concluded that planned VBAC is a reasonable choice in nearly all cases. Research makes it clear that both VBAC and repeat cesarean section have potential benefits and harms. Even if every woman understood clearly these harms and benefits, some would choose VBAC and others would choose repeat cesarean, because different women have different values, needs, and circumstances. Factors like the amount of postpartum support a woman will have, her plans for future children, her feelings about her first birth experience, and many others may weigh into a woman’s decision about VBAC. Every woman should
have the opportunity to carefully weigh the benefits and potential
hazards of planned c-section versus planned VBAC and make the decision
she feels is right for her, her baby, and her family.

Informed
consent is a process to help you decide what will and will not be done
to you and your body. In the case of maternity care, informed consent
also gives you authority to decide about care that affects your baby.
The purpose of informed consent is to respect your right to
self-determination. It empowers you with the authority to decide what
options are in the best interest of you and your baby. Your rights to
autonomy, to the truth (as best as it can be known at the time), and to
keep yourself and your children safe and free of harm are basic human
rights. As the person receiving care and mother of your baby, you are
in the best position to decide what risks are important to you.

Whether
you wish to plan a VBAC or a repeat c-section, it is important to make
this decision on the basis of complete, accurate, unbiased information.
In practice, you will not always have access to your choice, as
providers, hospitals and birth centers also have rights and may choose
not to offer some types of care. However, others in your community or
surrounding communities may offer the type of birth you want, including
emotional support that addresses fears or anxieties that you may have.

In
many cases, where some caregivers would recommend a cesarean, others
would disagree that a cesarean is necessary. When the situation is not
urgent, you have time to discuss the advantages and disadvantages of a
cesarean with your caregiver or get a second opinion. You can consult this website's separate
Pregnancy Topic on Cesarean Section.

type of uterine scar not known: Many years ago, studies showed that a side-to-side cut on the lower part of the uterus (low transverse incision) produced a much stronger scar than the previously used vertical ("classical")
incision. As a result, virtually all women who had a previous cesarean
and are pregnant now have a scar that goes from side to side.
Exceptions may be a past cesarean for: placenta previa (placenta overlays the cervix), an emergency situation, premature (preterm) birth, or breech (baby in feet- or buttocks-first position). Your care provider will want to obtain the medical record from your previous birth to confirm the type of scar, since the direction of the scar on your skin may not be the same as the scar on your uterus. Even if the records are not available, however, research suggests that there is no increased risk for scar rupture when the direction of the scar is unknown compared with women with a known low-transverse scar.

previous cesarean for premature (preterm) birth: The lower
portion of the uterus may not have developed enough at the time of the
past cesarean to permit a cut that goes from side to side (transverse incision). For this reason, doctors may make an up-and-down incision at the bottom of the uterus (low vertical uterine incision). However, although research in this area is limited, the low vertical incision appears to be just as strong as a transverse incision.

baby expected to be larger than average: Some have thought that babies expected to weigh more than 8 pounds, 13 ounces (4,000 grams), so-called macrosomic or "big bodied" babies, would put extra pressure on the scar. However, studies don't show this to be the case.

pregnancy goes beyond the due date: Studies do not show an increase in problems with the scar in pregnancies going beyond 40 weeks, although some studies show an increase if labor is induced after this point.

twin pregnancy: Studies haven't shown an increase in
problems with the scar during labor with twins compared with one baby.
However, limited information on VBAC labors with twins is available at
this time.

baby is in a buttocks- or feet-first (breech) position:
Few care providers will agree to vaginal breech birth even when the
mother has no cesarean scar, so the question here is whether it is it
safe to have a procedure in which the care provider uses hand maneuvers
on the belly to try to turn the baby into a head-first position (external cephalic version). As with twins, we have little research on this point, but what little we have has not found extra problems.

Overall,
fewer than 1 woman in 100 who labor after a cesarean experiences the
scar giving way during labor, which generally leads to an urgent
c-section. Researchers have found that some factors increase this
likelihood. None of these factors raises this risk higher than 4 out of
100, and most do not raise it higher than 2 out of 100. In other words,
96 to 98 out of 100 women who have these factors will labor without any
problem with the scar.

In VBAC labors, loss of the baby occurs
much less frequently than scar separation and urgent c-section. In about 6 percent of uterine ruptures, the baby will die. Since uterine rupture is itself rare, the overall risk of losing a baby as a result of uterine rupture is extremely low, and equal to or lower than the risk of losing a baby as a result of other rare labor complications. A recent major government report found that, on average, over 5,200 planned repeat cesareans (and their associated risks) are required to
prevent the death of 1 baby as a result of problems with the scar.

The chance of having scar-related problems is higher if:

you have had more than one prior cesarean

you had a uterine infection following the previous cesarean

you are 30 years old or older

your due date is less than 18 months after the previous cesarean

your doctor used one layer of stitches rather than two when closing the incision on your uterus

If you decide to plan for a VBAC, due to the small chance of a scar causing problems, it may be wise to choose a hospital capable of handling an urgent cesarean at any time. To do this, the hospital must have obstetricians, anesthesiologists, and pediatricians immediately available around the clock and a blood bank that is open at all times. If these resources are not available in your hospital, you might consider planning to give birth in another setting where they are available. Some women will choose to accept the small risk so that they can give birth in their own community or with a familiar provider, however.

In
some rare situations, it is thought that substantially more women - 8 to
12 out of 100 or so - will have the scar give way. Almost all care
providers, including those who usually encourage VBAC, would strongly
recommend planned cesarean in the following situations:

certain uterine scars from a cesarean that aren't the usual horizontal cut made at the bottom of the uterus (low transverse scar): In these rare situations, the concern is that the scar on the uterus may be weaker and more likely to give way (rupture) and cause serious problems than the usual cesarean scar.

a high cesarean scar that runs up-and-down (vertical or "classical" uterine incision): a vertical incision may have been used if you had a placenta that grew over the opening to your uterus (placenta previa), for some urgent cesareans, or in some cases when previous baby was in a buttocks- or feet-first (breech) position. (It is possible to have a low horizontal scar on your skin but a vertical cut on your uterus.)

inverted T- or J-shaped incision

mother had previous uterine surgery for gynecologic problems, such as certain procedures for removal of fibroid tumors

uterine scar opened and caused problems in a prior labor: The key point here is that the scar has caused problems before. Many times, scar openings are small, harmless "windows" (dehiscences). These windows are not thought to have any ill effects in future labors.

ultrasound in late pregnancy finds that the area of the scarred uterus is unusually thin: There may be a concern if the scar is 2.5 millimeters thick (about the height of 2 stacked dimes) or less.

Some studies find a relationship between induction of labor and uterine rupture while others do not. A recent government report concluded that there is probably an increased risk of uterine rupture when labor is induced after 40 weeks, but not when it is labor is induced prior to 40 weeks.

The risk may depend on the methods used to induce labor. Agents used to soften and shorten the cervix (the opening to the uterus) may increase the likelihood that the scar will open and lead to problems in labor. Some researchers think these agents may soften the uterine scar as well. They belong to a family of hormone-like substances called prostaglandins. They may be put in a woman's vagina or, less commonly, given by mouth. Brand names include Cytotec, Cervidil and Prepidil. Of these, Cytotec (also known as misoprostol) appears to be the riskiest option and is now considered contra-indicated (experts agree it should not be used) in VBAC labors. Use of a foley catheter, a mechanical method to soften and open the cervix, does not appear to be any riskier than medical agents, but more research is needed.

Using synthetic oxytocin (Pitocin or "Pit") by itself to try to start (induce)
labor may also increase the likelihood that the scar will give way, but oxytocin appears to be safer than prostaglandins. Giving oxytocin in labor to strengthen contractions (labor augmentation or stimulation) may also increase the risk of scar problems.

If your caregiver recommends induction to you, it is important to consider together the risks and benefits of waiting for labor to begin on its own, inducing labor, or scheduling a cesarean section. Because of the possible increased risk of uterine rupture, as well as other known risks of induction, it is important to consider induction only when there is a clear medical reason and to avoid induction for convenience or for reasons that are not clearly supported by research. The Induction of Labor topic on this web site reviews the medical reasons for induction and provides more information about risks and benefits.

If
you have already had a vaginal birth (in addition to your c-section),
you are more likely to reach a goal of VBAC than a woman who has not
had a vaginal birth. Your chance of having a vaginal birth also depends on choices you make during pregnancy and how you are cared for in labor. To learn more about these factors, see the question, "If my goal is VBAC, how can I increase the likelihood of giving birth vaginally?" in Tips and Tools.

VBAC is associated with risks and
trade-offs, so deciding whether to give birth vaginally after c-section
is a choice that only you can make. Studies that have looked at the following factors have found that despite these disadvantages half or more of women who planned VBAC achieved their goals:

suspected big baby

slow or stalled labor as the reason for the previous cesarean

going past the due date

more than one previous cesarean and others.

A recent government report analyzed tools that help predict the likelihood of vaginal birth and found that these tools are good at identifying women with a high likelihood of vaginal birth but are not as good at identifying women unlikely to have a vaginal birth. Several factors that affect chances of vaginal birth, such as caregiver attitudes and factors that come up in labor, are not measured by these tools.

If
you can identify what elements of your labor distressed you, you may be
able to avoid repeating the problem. Here are some ideas:

If you feel that you didn't have good supportive care from your caregivers, you may wish to choose a different caregiver, birth setting, or both. The Choosing a Caregiver and Choosing a Place of Birth topics on this site can help.

If you feel that you didn't get the support you needed from your partner or others who were with you, hire a doula (trained labor support companion) or invite a friend or relative to assist you and your partner. The Labor Support topic on this site has more information about doulas and resources for finding one.

If the problem is the frustration of long, non-productive hours in labor or pushing, you can:

know that your next labor may proceed very differently; the first is usually the longest.

learn about factors that can interfere with labor progress and
gather ideas on how to help labor progress more smoothly. This is
another reason to hire a doula as she will know these things.

decide ahead of time on reasonable limits for the cervix to dilate
fully and then for you to push the baby out. Knowing you have an end
point can help you feel less anxious and more in control. If you reach
this point, you can choose whether to go beyond it. Keep in mind when
setting limits that women with prior cesareans tend to labor more like
first-time mothers than women who have given birth vaginally.

Have patience. The length of normal labor varies. Women with good support, encouragement, and the full range of comfort and pain relief options available to them can cope with longer labor.

If your concerns are with the pain of labor, become informed
about epidurals, which tend to offer effective pain relief, and
consider planning to have one. A doula can also help with many measures for comfort and calming in labor.

Although
many pregnant women have moments of apprehension about labor, some
experience continuing deep-seated fear of labor. If you find yourself in this situation, you should know that a series of counseling or psychotherapy sessions during pregnancy help many women overcome such fears and keep their options open. If you decide to seek counseling, be sure to get help
from a trained individual who has both good counseling skills and an
understanding of maternity issues. With this help, about one-half of
women who previously requested planned c-section change their minds.
Continuous support during labor by a trained labor support companion (doula)
may also be of special value in this situation. If you still have deep
fears of childbirth despite counseling, cesarean birth may be your best
option. Should this be your choice, Tips & Tools: VBAC or Repeat C-Section can help you have a safer and more satisfying cesarean birth.

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